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Chapter 17
chapter 17
Question | Answer |
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Once a nurse assesses a client's conditon and identifyies appropriate nursing diagnosis | plan is developed for nursing care |
Planning is a category of nursing that involves: | Client -centered goals and expected outcomes are established |
Priorities are establised to help the nurse anticipate and sequence nursing interventions when a clent has multiple problems or alerations. Priorities are determented by the client's: | Urgency of problems |
A client-centered goals is a specific and measurable behavior or response that reflects a client's | Highest possible level of wellness and independence in function |
For client's to participate in goal settings, they should be | Alert and have some degree of independence |
The nurse writes an expected outcome statement in measurable terms. An example is: | client will report pain accuity less than 4 on a scale of 0-10 |
As goals, outcomes and interventions are developed the nurse must | Be aware of and committed to acceptable standards of practice from nursingand other disciplines |
When establishing realistic goals the nurse: | Knows the resources of the health care facility family and client |
To initate an intervention the nurse must be completent in three areas, which include | knowledge, function, and specific skills |
Collaborative interventions are therapries that require | Multiple health care professionals |
Client-centered goals | is a specific and measurable behavior or response that reflects a client's higher possible level of wellness and independence in function |
Callaboration | the nurse taps the best resources to individualize nursing interventions |
Nurse initated interventions | are the independent response of the nurse to the clent's health care needs and nursing diagnosis. |
Nursing care plan | is a guide for clinical care. It also serves as a document that communcates a client's nursing care to all member of the health care team |
Physician initated interventions | are based on a physician's response to treat or mange a medical diagnosis. |
planning | is a category of nursing behaviors in which clent -centerd goals and expected outcomes are establised and nursing interventions are selected |
Scientific rationale | is the reason that, based on supporting literature, a specific nursing action was chosen |
Short term goal | is an objective that is expected to be achieved within a short time frame, usually less than a week |
Well-formulated, client centered goal should | Meet immediate client needs. Include preventative health care needs. Include rehabillitaion needs. |
The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free frim infection throughout hospitalization. This statement is an example of a | Short -term goal |
The following statements appear on a nursing care plan for a clentafter a mastectomy: Incision site approximated; absence of drainage or prolonge erythema at incison site; and clent remains afebrile. These statements are example of | Expected outcome |
The planning step of the nursing process includes which of the following activities? | Setting goals and selecting interventions |